Buckinghamshire, Oxfordshire and Berkshire West ICB (BOBICB)
The July Board heard that by Month 2 of the current financial year this system was £10.9million adrift from the planned position. The problem was blamed on inflation, industrial action, staff shortages, and under delivery of planned efficiencies/ savings. The Board was told BOB ICS was “not alone in facing these challenges, with NHS SE providing support.” (p3-4)
However by the end of month 4 the deficit had risen to £47.1m – compared to a planned deficit of £19.0m (i.e. £28.2m worse than plan). £12.6m of this was due to the ICB itself overspending by £12.6m, “due to pressure in prescribing, continuing healthcare, mental health placements and independent sector activity for ophthalmology.” (p1)
The ophthalmology spending was down to “continued over activity at Independent sector providers of cataract surgery driven by patient choice.” (p3)
The other main culprit was said to be Oxford University Hospitals trust, which had not delivered its full savings targets, and was spending £16.1m above planned level: worse still OUH was relying heavily on one-off measures to make savings, stacking up problems for next financial year. OUH’s finances appeared to have worsened by £2.4m in the previous month, but excluding these one-off items the deterioration would have been £6.4m. (p3)
While the ICS forecast was held at breakeven for the year, action was required to achieve this. There is a mountain to climb to stand any chance of breaking even with just six months of the year left to make changes. The September Board meeting was told that out of gross system risk of £160.3m at M4 just £67.7m of “mitigating” measures (42% of the total) had been identified, leaving a gap of £92.9m.” (p1)
£11m of Elective Recovery Funding has been withheld by NHSE pending provider delivery of elective activity targets. However the Board is warned:
“It is unlikely that providers will deliver the target activity particularly in the light of the ongoing industrial action by junior doctors and consultants.” (p6)
And while the running cost of the ICB is currently reported as on plan, this has only been achieved by leaving senior posts vacant:
“The costs of the new organisational structures are in excess of allocation but are not fully recruited to at this stage. The ICB would overspend its running cost allocation if all posts were to be recruited. A vacancy control panel is now in place and the ICB is expected to achieve breakeven. The ICB also needs to plan for a running cost reduction of 20% in 2024/25 and a further 10% in 2025/26.” (p4)
So broke is the ICB that one of the financial uncertainties of the Oxford Health Foundation Trust (mental health and social care) is whether, and how much the ICB will pay up for commissioning local services, as well as a risk that the Trust may miss the agency ceiling target – and drive the ICS over the capped limit on agency spending. (p9)
Oxford University Hospitals still faces unmitigated risks of £75.4m, and has been running at an underlying deficit of £6-7m per month (p9).
This is sharply increased from an average £2.5m per month in 2022/23. According to the Operational Plan, the main drivers of the OUH deficit are the slow start up of efficiency schemes, the impact of industrial action and inflationary pressures. (p5)
This is a real problem, because OUH planned efficiencies account for 41% of the ICS total. BOB’s deficit plan proposed 4.4% efficiencies, double the 2.2% required by NHS England’s operational planning guidance.
However the actual delivery at month 4, one third the way through the year, was £8.0m behind plan and less than one eighth (12.4%) of the full year plan. OUH phased £60m of their planned efficiencies evenly across the year, but things have worked out very differently:
“Discussions with the Trust indicate that efficiency delivery is unlikely to improve in the short term.” (p5)
The Integrated Care Board runs one of the most out of date websites of almost any ICB, and only meets bi-monthly. With no meeting in August, September’s ICB run as an AGM (video but no documents) and no October meeting advertised, the most recent relevant financial details are from June 2023.
This big gap between business meetings means that by the time the Board gets any real idea of the scale of the financial problems it’s likely to be too late to change much.
It’s difficult to get any idea of the actual problem because Frimley’s financial projections are also presented differently from other ICBs. The June papers, alluding to details in an even earlier meeting, report:
“The 23/24 gross deficit is £147m, 10% of the system allocation. The profit on disposal and the benefit of 22/23 non recurrent items has reduced this deficit to £99m, 6.8%. …
“Efficiency plans for FHFT and the ICB have been identified totalling £65.4m, of which £36.6m are considered to be low to medium risk. The remaining £38.8m is higher risk schemes in terms of delivery.” (p24)
Any additional proposed savings would of course be at even higher risk again, but that is the only way Frimley could claim to have a “balanced plan”, and so they included the improbable savings as “a further system stretch of £33.8m” (i.e.no actual plan at all). (p24)
The Joint Forward Plan 2023-2028 estimates that the Frimley system has “an underlying deficit in excess of £151m that is being supported by short term saving opportunities or additional non -recurrent national funding.
It sets the target of reducing costs, through a “System Financial Sustainability plan”. (p130)
Among the challenges to be confronted while also cutting costs to tackle the underlying deficit are:
- a 21% increase in hospital length of stay in the last 2 years across the patch
- c.20% beds filled by Medically Optimised patients at any one time [for lack of suitable services and capacity outside hospital to discharge them]
- An 80% increase in numbers of patients with a Length of Stay more than 21 days equating to more than 160 more patients – [and leaving fewer beds available for emergencies and elective patients]
- Elective and diagnostic capacity reduced due to estates safety concerns at Frimley Park (RAAC Plank failure risks) and other service pressures. (p101)
Brave plans for the Proactive Management of High Risk Patients seek to
“Support up to 20,000 complex and frail patients and Care Home residents using remote technology via two centralised monitoring hubs.” (p104)
The plans also include the roll out of remote monitoring to care homes … across 135 homes, and the ICB claims the system is “On track to ensure 5,500 patients passed to digital health team by the end of 2023.”
However the plan is set out with no costings or discussion of capital costs and staffing requirements, raising real doubts as to whether a system with such a substantial underlying deficit and such flimsy monitoring of its finances could deliver the proposals. We will have to wait at least until next month – just weeks before the end of 2023, to find out how it’s going.
Hampshire and Isle of Wight ICB
The September Board heard that the ICS had submitted a plan for 2023/24 that projected a £118.4m deficit, and has been put on the NHS England equivalent of the naughty step.
“As a result the whole system has requested entry into segment 4 of the NHS Oversight Framework. This requires additional assurance and reporting requirements to NHSE as well as some additional controls on spending decisions.” (p3)
However by Month 4 the ICS was already way of course, and closing in on the projected deficit for the whole year. The system as a whole was £107.1m in deficit (£24m (28%) above the planned level of £83.1m), with the ICB £5.8m (22%) deeper in deficit and Providers £18.2m (33%) worse than plan. (p4)
Most surprising is the lack of any obvious sense of urgency or likely major changes to respond to the deficits:
“A number of organisations are off plan to some extent in the first 4 months. This reflects specific pressures associated with industrial action, as well as under delivery of the planned level of efficiency savings. All organisations are forecasting delivery of their plan by year end and are collectively committed to achieving our planned position as a system.” (p4)
There is no sign that the ICB has an answer to the requirements set out in a letter by NHS England’s regional director:
“We … expect that by the end of quarter 2 your system will prepare a medium-term financial plan, demonstrating how recurrent financial sustainability will be delivered. This plan should clearly demonstrate how the recurrent exit run-rate from 2023/24 will be consistent with this, and how this run-rate will be improved through 2023/24.” (p11)
As things stand there is no way such a plan can be credibly produced.
Meanwhile the Performance Report to the September Board meeting shows a decline or continued failure of the system on a whole series of measures, including:
- 4-hour Type 1 Accident and Emergency Department performance declined in July against June, the lowest attainment for 3 years and below national average
- Patients who no longer meet the Criteria to Reside (CTR) and have not been discharged remains stagnant at over 600 (20% of total General and Acute beds)
- Ambulance response times deteriorated for South Central Ambulance Service (SCAS) across all 4 metrics – Trust did not achieve the 30- minute operating plan standard for Category 2
- 12 Hour waits remain significantly challenged on the Isle of Wight – significant deterioration in latest month
- Total waiting list continues to increase, as do the number of 18-week breaches.
Kent and Medway ICB
The ICS had a £50.5m deficit in Month 4, £30.9m adverse to plan. The Board is warned of the increasing red-rated risk to ‘Deliverability of the 2023/24 financial plan’, noting that this year’s plan was submitted to NHS England despite having no efficiency plans in place to tackle more than half (£135m) of the system efficiency target of £259.2m. (p49)
By Month 4 the ICB seems to have made little further progress, still seeking ways to save more than half (£112m) of the outstanding financial risks of £211.2m. The risk level has been increased from 16 to 20 in the red zone. (p49)
The ICB has set up a System Sustainability and Transformation group “attended by all the NHS Provider Chief Executives,” which has sweeping terms of reference to review the configuration of “all locally provided NHS clinical services,” and:
“• Consider if any services location should be consolidated.
- Identify those services where short, medium- and longer-term moves may support improvements.
- Specific consideration of EKHUFT in the absence of capital funding for a new hospital.
- Identify reconfiguration options.
- Financial consequences of options to deliver financial balance.” (p25)
The September Board meeting heard that:
“This group has now met and has reviewed and agreed a draft case for change together with the common financial recovery model. The group will continue to work together on the ‘fragile’ services review, service models and work through the specialist commissioning delegation.” (p26)
However no minutes are revealed of the meeting of what appears to be an ad-hoc committee. The draft plans, agreed by a closed cabal of senior NHS bosses – and quite probably including management consultants (see reference to support from Carnall Farrar, p45) – have not been published with the Board papers, and there seems to be no plan to put proposals to consultation even to the Board meeting.
This suggests strongly that Kent and Medway have joined the infamous list of ICBs that have been drawing up major cash-driven plans to reconfigure services in private sessions of Board meetings or in other gatherings where press and public are absent. This makes it impossible for local communities who are likely to be affected by the changes to have any say, or even be aware that changes are on the agenda.
Concerns that a secretive process aimed at far-reaching cash-driven reconfiguration and cutbacks is developing under the cover of the urgency of the financial problems are reinforced by the steps being taken to address the deficit:
“1. ICS CEOs group will review (a) elective recovery (b) financial performance (c) financial recovery – ongoing throughout 2023/24
“2. Work up and implement, at pace with support from NHSE approved consultancy, efficiencies to address gaps – ongoing throughout 2023/24.” (p49)
And while there is no mention of any consultation with the public or with trade unions, on what could be substantial changes, there is the far-from reassuring commitment to accountability … upwards to NHS England: “to keep them abreast of actions that the system is taking to deliver the financial plan….” (p49)
But while there is no information on how the big savings are to be made, and how services might be reconfigured as a result, the Board papers include a lengthy 170-page Decision-Making Business Case on a small-scale £4 million scheme to centralise “place of safety” mental health services – to which there seems to be no opposition (pages 103-273 of the pdf).
Nor are the local press and public likely to find it easy to decipher the state of play in local services from an Integrated Performance Report presented entirely in far from clear graphical form without any textual explanation or comment. (p54-77)
Surrey Heartlands ICB
The ICS has slipped from a £5.3m deficit from plan in Month 2, and the assurance that: “The plan was high risk but the deficit would reduce through the financial year,” (p9) to a £25.1m deficit, £20.6m above the planned level of £4.5m at Month 4. (p1)
According to the September Board papers the deficit is explained as:
- £8.3m is related to providers and is driven by pay cost variances which are attributable to costs of backfill arising through industrial action, efficiency targets and stretch in the plan not achieved, and increased RMN costs associated with mental health patients in secondary acute settings.
- £12.3m is related to non-acute ICB expenditure and is driven by a significant increase in practice prescribing costs (£8.0m or 16% YTD) as well as higher package of care costs in CHC (£1.6m).
With the financial plan hanging on achieving £158.5m of planned efficiencies across acute and non-acute services, reported efficiencies were 30% short of plan at month 4 (£30.2m compared with plan of £42.8m). Agency costs were 13% lower than last year and 5.3% lower as a percentage of total pay, but are still higher than the 2023/24 NHSE ‘cap’ of 3.7%. (p5)
The CEO’s report to the September meeting welcomed the opening of the new Mary Seacole Unit, created by merging various units into the Langley wing at Epsom Hospital:
“The Alex Frailty Unit and New Epsom and Ewell Community Hospital (NEECH), part of Surrey Downs Health and Care, have moved from Wells Wing and the West Park site in Ewell respectively, to a newly refurbished 38-bed unit, called the Mary Seacole Unit, on the first floor of Langley Wing at Epsom Hospital.
“The new Mary Seacole Unit will operate as one fully integrated unit, providing inpatient frailty and rehabilitation services for local people under an integrated leadership team (including medical, nursing and therapy leadership).
“… Therapy services, including The Poplars neuro-rehabilitation service and MSK outpatient services, have also moved from West Park, and are located on the ground floor.
“Langley Wing is now an integrated care hub, completing the final part of its redevelopment, and aligning with the future district hospital model, which will see both Epsom and St Helier focus on providing excellent rehabilitation, outpatients, diagnostics, and urgent treatment services to 85% of people who need care or treatment with us.
“This will include district beds for patients ‘stepping down’ from the specialist emergency care hospital, ‘stepping up’ from the community and directly admitted via an urgent treatment centre.” (p9)
While the integration of these services seems to make perfect sense, it remains to be seen whether just 38 beds to deal with the need for frailty and rehabilitation services not only across the population of Surrey Heartlands but also the Epsom & St Helier trust’s catchment area of South West London.
Moreover, despite the smug CEO boasts over the new unit there are likely to be logistical issues of delivering services for frail elderly people in a ‘centralised’ site close to the London edge of the ICS boundaries, and some distance from much of the Surrey Heartlands area, with less than perfect public transport links and congested roads to negotiate. What might make organisational sense for the providers and the ICB may well prove to be a long term major hassle for patients accessing outpatient services, and for relatives trying to visit patients in the 38 beds.
After concluding 2022/23 with a deficit of £15m (p11), NHS Sussex ICB was reporting a break-even position at month 2 of 2023/24, and even a £37k surplus.
The Sussex system as a whole, however was reporting £6.1m adverse to plan, £2.8m of which was due to factors outside of its control, such as industrial action, inflation and elective recovery clawback, with the remainder due to delivery of cost improvement plans and agency costs.
There were significant risks to delivering the break-even plan, including the ICB achieving a £64m efficiency plan (some elements of which were still being worked up). Problems include increasing Prescribing costs and increasing demand for Continuing Healthcare. (p9-10)
By Month 4 however the system had run into trouble, with a deficit of almost £21 million in the first four months of the year, £11 million worse than plan.
This was attributable to University Hospitals Sussex (£7.1 million adverse), Sussex Partnership (£2.6 million adverse) and East Sussex Healthcare (£1.3 million adverse).
The additional costs were largely driven by inflation above the planning assumptions, unplanned costs associated with industrial action, and additional agency costs, in particular due to Mental Health pressures across the system. (p4)
NHS Sussex was still forecasting the achievement of its break-even plan by the end of the year, but at least £32 million of significant financial risk is still unresolved.
The ICS needs to find ways to make savings big enough to cover increasing prescribing costs and Continuing Health Care expenditure. And having secured NHS England approval for its 2023/24 Operating Plan on the strength of a £208 million efficiency plan for the whole year, plus a £4m “stretch efficiency target” [i.e. a promise of savings for which there were no plans] they still have to find ways to achieve these targets as well. (p4)
The Finance & Performance Committee was pleased to note that the operating theatre utilisation in Sussex is one of the highest in the country: but despite this the total waiting list for treatment in Sussex increased from 114,000 in February 2020 to 236,000 in August 2023, and is forecast to increase by a further 18% to 278,000 by 31 March 2024. The Committee was told industrial action [rather than lack of capacity to meet rising demand] will be held responsible for at least 80% of this 42,000 forecast growth in the total waiting list. (p7)
Winter Resilience planning centres on delivering the “comprehensive discharge improvement plans” which have been agreed between system partners. It is hoped these plans will
“reduce the number of NCTR [No Criteria To Remain] patients from 477 to 320 (a reduction of 157) and will release the equivalent number of beds, improving capacity, reducing the risk to patients of de-conditioning.” (p8)
But the plans amount to increasing the capacity of the system by expanding the availability (and therefore the number) of “appropriate places of residence” outside hospital. This creates the strong likelihood that the 157 vacated NHS beds will swiftly fill once more, after their long-staying occupants have been moved on.
In other words ‘resilience’ in the system comes at a cost of additional spending on facilities – and also needs additional staff in the community and primary care to ensure patients are supported rather than returning once more to hospital.
All of this costs money: but no costings or staffing issues are discussed in the report.
Only much later on in the report is there an explicit reference to financial costs
“The resourcing of the System Coordination Centre (SCC) to allow the delivery of [NHS England’s] new SCC standards will need to be considered by the ICB following completion of the full impact assessment.” (p17)
After so many years of frozen budgets and real terms cuts in funding, it’s clear to all but ministers and NHS England that in many cases the ICBs with the biggest problems will need to be able to spend and invest more money before they can deliver genuine savings rather than outright cuts in services and staffing levels.
The resilience plan shows how the local demographics place a particular strain on capacity, stating:
“The 65+ age group make up 23.2% of the Sussex population and use 27.5% of A&E attendances and use 59.4% of non-elective spells.” (p11)
With such a high preponderance of older patients among in-patients we might expect the ICB to make itself well-informed on the issues of inequality and vulnerable populations, but instead they offer a “No shit, Sherlock” moment, announcing with evident surprise:
“If [A&E] attendances for the most deprived quintile were at the same rate as for the least deprived quintile, they’d have 21,637 fewer attendances per year; if nonelective admissions for the most deprived quintile were at the same rate as for the least deprived quintile, they’d have 9,525 fewer admissions per year.” (p12)
This really is the ultimate hypothetical proposition. Addressing this level of health inequality calls for long term and radical action way beyond the scope of the NHS and local government.
The task of the NHS and social care in Sussex is to find ways to cope with rising demand, and prioritise the health needs of the poorest and most vulnerable. This has been made more difficult by 13 long years of austerity funding, accompanied in recent years by empty ministerial waffle about “levelling up” and NHS England’s impossible demands for cash savings as the Chancellor tries to claw back the “extra” NHS funding during the Covid pandemic.
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